Notice of Privacy Practices

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• basis for planning your care and treatment• means of communication among the many health professionals who contribute to your care• legal document describing the care you received• means by which you or a third-party payer can verify that services billed were actually provided• a tool in educating health professionals• a source of data for medical research• a source of information for public health officials charged with improving the health of the nation• a source of data for facility planning and marketing• a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to:

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

• request that we not use or disclose your health information for a particular reason related to treatment, payment, the facility’s general health care operations, and/or to a particular family member, other relative or close friend. We ask that such requests be made in writing on a form provided by our facility. Although we will consider your requests with regard to the use of your health information, please be aware that we are under no obligation to accept or to abide by it, unless it is a request to prohibit disclosures to your health care plan relating to a service for which you have already paid in full out of pocket.

• obtain a paper copy of the notice of information practices upon request. To obtain a paper copy of this Notice of Privacy Practices, contact the facility’s Health Information Management Director.

• inspect and obtain a copy of your health record that may be used to make decisions about your care, which will be provided to you within the time period established by law. Usually this includes medical and billing records, but does not include psychotherapy notes, information compiled in reasonable anticipation of, or for use in a civil, criminal or administrative action or proceeding, and health information that is not discloseable under the Clinical Laboratory Improvements Amendments of 1988. You may make such requests orally or in writing; however, in order to better respond to your request, we ask that you make such requests in writing on our facility’s standard form. You have the right to request that documents maintained in your electronic medical record be provided in an electronic format, e.g., a PDF file. If the form(s) are not readily producible in an electronic format, the facility will work with you to provide it in a paper format. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

• amend your health record. This means you may request an amendment of health information about you for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact the facility’s Health Information Management Director if you have questions about amending your medical record.

• obtain an accounting of disclosures of your health information. You have the right to receive specific information regarding disclosures that occur on or after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions or limitations. This right does not apply to disclosures we have made for purposes of treatment, payment or healthcare operations or as part of a limited dataset as described in this Notice of Privacy Practices. This right does not apply to disclosures we have made pursuant to an authorization you previously provided to us or to incidental disclosures. It excludes disclosures we may have made to you, for a facility director, to family members or friends involved in your care, or for notification purposes.

• revoke your authorization to use or disclose health information by providing us with written notice of your revocation except to the extent that action has already been taken in reliance on your authorization.

• file a complaint with the facility’s Executive Director or with the Secretary of Health and Human Services if you believe your privacy rights have been violated.

Our Responsibilities

The facility is required to:

• maintain the privacy of your health information.

• provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.

• abide by the terms of this Notice of Privacy Practices.

• notify you if we are unable to agree to a requested restriction.

• accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

• notify you following a breach of unsecured health information.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post the changes in a

public area in our facility, as well as on our web site. We will not disclose your health information without your authorization, except as described in this Notice of Privacy Practices.

Examples of Disclosures for Treatment, Payment and Health Operations

• We will use health information about you to provide you with medical treatment or services.

For Example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.

• We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from this facility.

• We will use your health information for payment.

For Example: A bill may be sent to you, an insurance company or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

• We will use your health information for regular healthcare operations.

For Example: Members of the medical staff or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples include certain laboratory tests and some consultants who provide services for care within the facility. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information, which they are also required to do by law.

Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people that ask for you by name.

Notification: Unless you notify us that you object, we may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. If you are not present or able to agree or object to the use or disclosure, we will use our professional judgment to determine whether the disclosure is in your best interest.

Communication with Family: Unless you notify us that you object, health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. If appropriate, these communications may also be made after your passing, unless you have instructed us not to make such communications.

Photographs and Memory Boards: Photographs or videotape may be taken of you as a means of identification in case of emergency or for health-related purposes. If you provide authorization, photographs also may be taken for holiday activities, memory boards, cue boxes and “Resident of the Month”. In addition, if you provide authorization, the facility may display within the facility a written summary about your life history, hobbies, and/or personal information to provide resident cueing and enhance quality of life.

MDS Transmission: Skilled nursing facilities for Medicare and Medicaid are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident’s functional capacity and health status. This information is used to aid in the administration of the survey and certification of Medicare/Medicaid long-term care facilities and to improve the effectiveness and quality of care given in those facilities. The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing homes and is also necessary for the nursing homes to receive reimbursement for Medicare services.

Research: We may disclose information to researchers when the information does not directly identify you as the source of the information or when a waiver has been issued by an institutional review board or a privacy board that has reviewed the research proposal and protocols for compliance with standards to ensure the privacy of your health information.

Funeral Directors and Coroners: We may disclose health information to funeral directors consistent with applicable law to carry out their duties. We may also disclose health information to a coroner or medical examiner for identification purposes when determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.

Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Marketing/Sales: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We will require your authorization before any use or disclosure of your protected health information for marketing purposes, and we will not sell your health information without an authorization from you.

Fund Raising: We may contact you as part of a fund-raising effort; however, you will be provided an opportunity to opt out of these communications.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Disaster Relief: We may use or disclose health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating with respect to notifying, identifying or locating your family members or personal representative.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena, court order, warrant, summons, or similar process.

De-Identified Information: We may use health information for the purpose of creating de-identified information or disclose health information to a business associate for the purpose of creating de-identified information. De-identified information is information that does not identify you and that we reasonably believe cannot be used to identify you.

Personal Representative: If you have a personal representative such as a legal guardian, we will treat that person as you with regard to disclosure of your health information. Should you be deceased, we will treat your executor, administrator, or other person with authority to act on your behalf as your personal representative under the same circumstances that we would disclose such information to you and as otherwise provided or required by law.

Use and Disclosures of Health Information Based Upon Your Written Authorization: Other uses and disclosures of your health information will be made only with your written authorization unless otherwise required by law.

Limited Data Set: We may use and disclose a limited data set that does not contain specific, readily identifiable health information about you for research, public health, and health care operations. We may not disseminate the limited data set unless we enter into a data use agreement with the recipient in which the recipient agrees to limit the use of that data set to the purposes for which it was provided, ensure the security of the data, and not identify the information or use it to contact any individual.

Health Information Organizations/Exchanges: We may participate in a regional arrangement of health care organizations who have agreed to work with each other to facilitate access to health information that may be relevant to your care. As permitted by law, your health information may be shared with this organization/exchange in order to provide faster access, better coordination of care, and assist providers, hospital systems and public health officials in making informed decisions regarding your care. This information is stored electronically in a joint manner with other health care providers who participate in this regional arrangement.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the facility’s Executive Director.

If you believe your privacy rights have been violated, you can file a complaint with the facility’s Executive Director or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.